1992915805 NPI number — DR. JUSTIN MARK LAREAU

Table of content: DR. JUSTIN MARK LAREAU (NPI 1992915805)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992915805 NPI number — DR. JUSTIN MARK LAREAU

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAREAU
Provider First Name:
JUSTIN
Provider Middle Name:
MARK
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992915805
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/07/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
550 W OGDEN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HINSDALE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60521-3186
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-323-6116
Provider Business Mailing Address Fax Number:
630-323-6169

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1010 EXECUTIVE DR
Provider Second Line Business Practice Location Address:
SUITE 250
Provider Business Practice Location Address City Name:
WESTMONT
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60559-6135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-920-2350
Provider Business Practice Location Address Fax Number:
630-920-9381
Provider Enumeration Date:
05/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  036124358 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036124358 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com